Thursday, May 3, 2012

Erich Fromm #2: What is humanistic psychiatry?

“The reasons why social scientists have not considered the question of the optimal social conditions for man’s* growth a matter of primary concern can be easily discerned if one recognizes the sad fact that, with a few outstanding exceptions, social scientists are essentially apologists for and not critics of the existing social system.” (Erich Fromm, AoHD, 292)

“The majority of psychologists, like most social scientists, are not prone to doubt the system. In fact, their theories are not only influenced by it, but help to support it ideologically. They do not transcend the basic axioms even in their experiments, most of which tend to prove the basic premises of our society scientifically.” (Erich Fromm, PoN, KL 1662-5)

In this first substantive post of the Erich Fromm series, I’ll discuss Fromm’s critique of mainstream psychiatry and social science – that they’re a tool of the status quo, aren’t grounded in humanistic values, and have become alienated and
scientifically shallow - and his vision for a humanistic psychiatry,which would serve human needs, be dedicated to realizing humanistic values, and be genuinely scientific and unalienated. The discussion will draw primarily
from The Pathology of Normalcy (PoN)

and also from The Anatomy of Human Destructiveness (AoHD)

In Fromm’s time - the mid-twentieth century – though psychoanalysis still dominated in professional psychiatry, other models were strong in the social sciences and the popular imagination. The corporate-neuropsychiatric
model that’s triumphed today was then in its infancy, but it would come to elaborate so many of the features Fromm challenges that his work can be read as a prescient indictment of it as well.

Psychiatry’s service to the status quo

Fromm argues that society, any society, pushes people to fill useful molds, and preferably to do so willingly. “One of the great efforts which every society makes,” he argues,

in its cultural institutions, educational institutions, religious ideas, and so on, is to create a type of personality that wants to do what he or she has to do; which is not only willing but eager to fulfill that role which is required in that society, so that it can function smoothly. (PoN, KL 197-200)

The profession of psychiatry isn’t immune to these societal demands. The most basic criticism Fromm has of psychiatry and social science is that they tend to serve the needs of the system in which they operate. They accept the definition of mental health embodied in societal norms, and work – not always consciously, of course – to adjust people to the system and to supply more to feed it. The “principle of adjustment” underlies psychiatry, in Fromm’s time and in ours. This defines mental health primarily in terms of adjustment to the needs of the society and mental
illness as “a deviation from what is the personality type that this society wants” (PoN, KL 171-174).

As Fromm explains, the assumptions underlying the principle of adjustment are of two types. The first is relativistic: the desired personality types of any “functioning” society represent an acceptable norm. The second
rejects this relativism but claims that our society has reached such a pinnacle of human development – “the American way of life happens to be the end and fulfillment of human aspiration” (PoN, KL 214-17) - that a person’s failure or refusal to function contentedly within it must be due to pathology.

In both cases, the role of scientific psychiatry is to determine the individual causes of maladjustment and to help the person to resume functioning in their role in society. Psychiatry assumes, Fromm argues, that

the aim of mental hygiene, the aim of psychiatry, the aim of psychotherapy, is to restore man to the ways of the average personality, regardless of whether they are blind or he is blind.** What matters is that he is adjusted and that they are not disturbed. (PoN, KL 171-174)

It would be hard to find too many people today who would explicitly make the claim that our society (much less every one of those in which the brain-pathology model is applied) is ideal or even particularly sane, such that mental illness could be judged with reference to it. Few would argue outright that the problems of, say, a woman in Afghanistan are caused by an imbalance of neurochemicals. But one or both of these assumptions are at the heart of the contemporary model, in which psychological problems are understood to be located in individual brain chemistry or thought patterns. Problems, the model assumes, are not with society but with people’s brains. At the very least, the nature of the society a person lives in is largely irrelevant to the question. Regarding problems as essentially individual amounts to assuming the social context is fine and should be adjusted to.

The loss of humanistic values in psychiatry

“[T]he relativism with which the social sciences are imbued,” Fromm argues, unmoors psychiatry from humanistic values:

Whereas we still pay lip service to the great humanistic tradition, most social scientists have adopted an attitude of complete relativism, an attitude in which values are considered a matter of taste but of no objective validity. Because it is a difficult task to probe the objective validity of values, social science has chosen the easier path of throwing them out altogether. In doing so, it has neglected the fact that our whole world is endangered by the increasing loss of a sense of values, which has led to an increasing incapacity to use constructively the fruits of our thoughts and efforts in the natural sciences. (PoN, KL 1445-1450)

While Fromm speaks of the social sciences generally here, we can focus specifically on psychiatry. (Again, the narrowness and value-relativism are not always conscious or explicit, but are nevertheless inherent features of the model.)

Psychiatry has been overwhelmed by a corporate model based implicitly on the principle of adjustment and on value-irrelevance, in which psychiatry’s role is to find the pathologies in individuals and help them to be “happy,” and, more important, functioning members of capitalist society. This model effectively treats the causes of personal difficulties as irrelevant. Larger societal factors are simply ignored, while more immediate individual
experiences are relegated to the background.

Proponents can thus argue – leaving aside the very basic problems with the premises that drugs “work” or do so in some exclusive manner or that they don’t come with serious risks and side effects – that any physiological effects can and should be treated*** with drugs or other therapies focused entirely on the individual. Again, not many people would claim this model would be suited to, for example, Stalin’s Russia or Pinochet’s Chile, but this globally applicability and the principle of adjustment are in fact among its implicit premises.

Alienation and superficial science

This system-serving psychiatry is alienated from people and empirical reality in several ways, according to Fromm. First, clinical practice has tended toward treating individual people as objects rather than full human beings. More broadly, the study of humans and their psychological problems has been abstracted from real lives in real political and economic contexts:

What one really means by scientific approach, both the layman and the social scientist, is essentially something that is done by manipulating intelligence. It is taken for a scientific approach to a psychological problem if one can express it in abstract figures, if you count, if you measure, even if your basic data doesn’t make any sense and has no meaning whatsoever. (PoN, KL 919-922)

Given the bashing the social sciences often take today from the ignorant, it seems useful to note that Fromm was not arguing that strong empirical work can’t be done in the social sciences. He himself was arguing for a scientific approach, and the work of many in the social sciences today is far different from the sort of “abstracted empiricism” Fromm and C. Wright Mills complained about (undoubtedly due in some measure to their influence). Mainstream psychiatry, though, has become even more severed from the humanistic tradition and used in the system’s employ. As Fromm notes, the “erroneous results and superficial treatment” of this abstracted and highly partial model “have a useful function as ideological ‘cement’, while the truth is, as always, a threat to the status quo” (AoHD, 292).

Fromm’s rejection of the principle of adjustment and argument for existential human needs

Seeking to contribute to a humanistic psychiatric model, Fromm rejects both bases for the principle of adjustment, arguing that, rather than accepting that any given society is a picture of sanity just because it exists (which no one who thinks about all of the societies that have existed and exist today could seriously believe) or making the patriotic assumption that not all societies are sane but ours is, a humanistic science of psychiatry should study human experience and seek to discover the empirical bases for human mental health and well-being.

He argues that humans’ existential needs – our requirements for experiencing real joy and fulfillment – transcend individual societies, and that we can’t simply assume that they’re represented in any given society’s norms. Rather,
we have to discover these all-important transcultural and transhistorical needs empirically. “According to the relativists,” he contends, “any norm is valid once it is established by the culture whether it is murder or love. Humanism claims that certain norms are inherent in man’s existential situation, and that their violation results in certain consequences, which are inimical to life” (PoN, KL 1481-1487). Mental health is, then, the condition in which these needs, the needs of life, are consistently satisfied. (I’ll describe these basic needs and Fromm’s definition of mental health in upcoming posts, but what’s important here is that Fromm thought the foundational job of humanistic psychiatry was to determine what we need, what’s best for human thriving, and to help individual people and societies construct mentally healthy lives.)

The renewal of humanistic values as the foundation of psychiatric work

So Fromm thought the values that should guide psychiatry, or any humanistic discipline, weren’t relative and couldn’t simply be discerned or assumed from those prevalent in a given society at a given moment. We have to derive
them through sustained analysis of past and present societies and by investigating scientifically the requirements inherent in our nature and our existential condition. He argues that on the basis of this work, general scientific
statements about these needs can be made with confidence,

[j]ust as the doctor or physiologist can make an objectively valid statement that we begin with one axiom, and that is: to live is better than to die, or life is better than death, then indeed this food is better than another one. (PoN, KL 186-189)

Modern anthropology and psychopathology and psychology can show that by studying the nature of humanity, by studying the problems of human existence, one can find, with as much empirical evidence as we have for the usefulness of vitamins, that these are the aims which make for the best and only satisfactory solution of the
complex problems of living and existence. (PoN, KL 378-81)

These needs should form the basis of humanistic values, and psychiatrists, like everyone else, should work to create those conditions and relationships that are conducive to their realization. This might seem obvious, until we recognize how far the current system and the mainstream alternatives have moved from this vision. While over the past several decades many in the social sciences have embraced more humanistic approaches, psychiatry has become even
more alienated and empirically superficial.

(Fromm’s focus on the realization of human needs counters the simplistic straw man that all critical psychiatry merely reverses mainstream psychiatry’s judgments, exalting what’s considered insane behavior as sane and vice versa, as well as the suggestion that humanistic psychiatry denies real psychological suffering. Fromm’s is not a negative of the image of contemporary psychiatry; it’s a far more sophisticated vision grounded in an evidence-based
humanism.)

For many, psychiatry’s turn away from humanistic commitments hasn’t been experienced, at least consciously or fully, as a loss, because as it’s moved further away from those messy humanistic concerns it’s gained in some circles the status of science, which itself is alleged to transcend the humanistic tradition, as well as the support of corporations. But Fromm argues that a scientific status based on a severance from humanistic concerns makes of psychiatry a sham science:

It is often said by social scientists that one condition of scientific enquiry is the absence of any self-interested or preconceived aims. That this is a naive assumption is clearly shown by the development of the natural sciences: they are to a large extent furthered and not hindered by practical aims and necessities. It is the task of the scientist to keep the data objective, not to study without aims - which are what give meaning and impulse to his work. (PoN, KL 1466-1471)

These general aims can be accomplished only if methods proper to the study of man are examined and developed. The
problem is not that of choosing between a scientific and a non-scientific study of man, but of determining what constitutes the proper rational method for the understanding of man and what does not. (PoN, KL 1461-1464)

In contrast to the view that a scientific psychiatry would eschew value commitments, then, Fromm contends that
only by developing and embracing humanistic values can the field become meaningfully scientific and useful to humans rather than to corporations and governments. Psychiatry, social science, and science should not simply try to win contentment and functioning within or adjustment to existing social conditions, but should seek to determine the conditions most suited to human well-being and development and work for their realization. This requires the study of evolution and nonhuman animals, comparative anthropology and sociology, and the history of ethical thought (for Fromm, unfortunately, religious thought plays far too large a role here, which proves quite detrimental to his analysis), including that of modern liberation movements. It’s only on the basis of this understanding that people can talk about mental health from a humanistic and rigorous position and work toward realizing it in individuals and societies.

Fromm’s call for an unalienated and less superficial approach

Fromm suggests that a psychiatric approach that treats people as isolated objects, that ignores human needs and
the values derived from their appreciation, that fails to concern itself with societal determinants of mental health, does not deserve to be called humanistic or scientific. In order to achieve these humanistic aims, of course,
psychiatry needs to move beyond the clinical realm and appreciate the character of contemporary society, to recognize how the larger system affects the possibilities for mental health.

While Fromm did argue that “The main form of coping with mental illness and trying to achieve mental health, is not primarily individual therapy, but is primarily the change of those social conditions that produce mental illness or lack of mental health in the various forms that I have tried to describe” (PoN, KL 1422-26), he didn’t hold that
psychiatry should disappear as scientists came to focus on analyzing and changing social conditions, or reject clinical work, in which he engaged himself. But he argued that all relevant work should be unalienated in concrete practice – should refuse to treat people as objects:

It has to be established what differences in approach exist between the study of things and the study of living beings, especially man. For instance, there is a difference between “the objective” approach, in which “the object” is nothing but an object, and an approach in which the observer at the same time relates empathically to the persons he observes. (PoN, KL 1471-4)

In a telling example, he characterizes an approach that contrasts with the emphasis which has grown so strong in our day on developing reliable (ahem) diagnoses and labels:

On the basis of such considerations, the Meyerian psychiatrists and Laing decline to use nosological labels at all. This change has largely resulted from the new approach to the mentally ill. As long as one could not approach the patient psychotherapeutically, the main point of interest was the diagnostic label, useful for the decision of whether or not to put him in an institution for the mentally ill.**** Since one began to help the patient by psychoanalytically oriented therapy, the labels became unimportant, because the psychiatrist’s interest was focused on understanding the processes going on in the patient, experiencing him as a human being who is not basically different from the ‘participant observer’. This new attitude toward the psychotic patient may be considered an expression of a radical humanism, which is developing in our time in spite of the process of dehumanization that is predominant. (AoHD, 394, n.35)

Conclusion

As I said in my introductory post, a truly humanistic psychiatry can’t simply consist of a rejection of religious or superstitious approaches or of criticism of the contemporary corporate, drug-based model. It has to be built on the secular concerns of (post-)humanism. Fromm imagined that psychiatry could be positively based – in aims and in practice - in humanistic values, that, instead of helping humans serve the system, it could become one force among many working to create systems that serve human needs.

*Fromm’s writing is ridiculously sexist. It doesn’t read as misogynistic, but it is, like I said, ridiculously sexist, as well as Eurocentric, in that way that only mid-twentieth-century thinking influenced by Freudianism, Marxism, and religious study could be. At the beginning of AoHD, he states that using more balanced gender pronouns is fetishistic and he has no intention of doing it, which wouldn’t. perhaps, be a major problem if women weren’t almost entirely ignored throughout his work and he weren’t so all-fired insistent on referring to “Man” in virtually every paragraph. In many instances, this can be brushed aside and the arguments read as applying to all humans even if he didn’t really seem to be thinking of women at all. In others, the sexism (and speciesism) is a fundamental problem for his arguments, and I’ll discuss those problems when they appear. There’s no way to get around the fact that his work is shot through with this annoying “Man” language, though, so I’ll simply note it and move on.